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For bites and clenched-fist injuries that are not infected, antibiotic therapy is usually not necessary for otherwise healthy individuals if the risk of wound infection is low (eg small wounds not involving deeper tissues that present within 8 hours and can be adequately debrided and irrigated).

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

How severe is the infection? Prophylactic antibiotic therapy may not be required if there is no established infection. (see list below for details on when antibiotic prophylaxis is required)

• No infection established (prophylaxis)
• Established mild infection (not involving deep tissues)
• Established moderate/severe infection

• Wounds with delayed presentation for washout (8 hours or more)
• Puncture wounds which can not be debrided adequately
• Any wounds on the hands feet or face
• Wounds involving deeper tissues (eg. bones, joints, tendons)
• Wounds in immunocompromised patients
• Wounds which also involve an open fracture (see open fracture section)
• Any cat bite

How severe is the infection? Prophylactic antibiotic therapy may not be required if there is no established infection. (see list below for details on when antibiotic prophylaxis is required)

• No infection established (prophylaxis)
• Established mild infection (not involving deep tissues)
• Established moderate/severe infection

• Wounds with delayed presentation for washout (8 hours or more)
• Puncture wounds which can not be debrided adequately
• Any wounds on the hands feet or face
• Wounds involving deeper tissues (eg. bones, joints, tendons)
• Wounds in immunocompromised patients
• Wounds which also involve an open fracture (see open fracture section)
• Any cat bite

How severe is the infection? Prophylactic antibiotic therapy may not be required if there is no established infection. (see list below for details on when antibiotic prophylaxis is required)

• No infection established (prophylaxis)
• Established mild infection (not involving deep tissues)
• Established moderate/severe infection

• Wounds with delayed presentation for washout (8 hours or more)
• Puncture wounds which can not be debrided adequately
• Any wounds on the hands feet or face
• Wounds involving deeper tissues (eg. bones, joints, tendons)
• Wounds in immunocompromised patients
• Wounds which also involve an open fracture (see open fracture section)
• Any cat bite

If patient has no penicillin allergy use:

OR if at increased risk of methicillin-resistant Staphylococcus aureus (MRSA) infection, in place of the regimen above, use:

Code for IV Amoxicillin+Clavulanate is: 3bit

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• For patients hypersensitive to penicillins who require intravenous or intramuscular therapy, seek expert advice
• Switch to oral amoxicillin+clavulanate (see dosage above) as soon as oral absorption is adequate and oral therapy is tolerated
• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• For bites and clenched-fist injuries that are not infected, antibiotic therapy is usually not necessary for otherwise healthy individuals if the risk of wound infection is low (e.g. small wounds not involving deeper tissues that present within 8 hours and can be adequately debrided and irrigated). Give presumptive therapy if the risk of wound infection is high
• In all cases, the patient's tetanus immunisation status must be ascertained and must be up to date and must be up to date
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites
• For wounds on the hands, feet or face, or if infection progresses despite antibiotic therapy, consider surgical consultation. Surgical advice may also be sought on the appropriateness of primary versus delayed wound closure

References:

See section on bites wounds and clenched fist injuries - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has a penicillin allergy use:

• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• For bites and clenched-fist injuries that are not infected, antibiotic therapy is usually not necessary for otherwise healthy individuals if the risk of wound infection is low (e.g. small wounds not involving deeper tissues that present within 8 hours and can be adequately debrided and irrigated). Give presumptive therapy if the risk of wound infection is high
• In all cases, the patient's tetanus immunisation status must be ascertained and must be up to date and must be up to date
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites
• For wounds on the hands, feet or face, or if infection progresses despite antibiotic therapy, consider surgical consultation. Surgical advice may also be sought on the appropriateness of primary versus delayed wound closure

References:

See section on bites wounds and clenched fist injuries - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy use:

Code for IV Amoxicillin+Clavulanate is: 5bit

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2bit

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• A longer antibiotic course may be required according to clinical response
• Depending on microbiological findings from wound swab, the usual oral step down for animal or human bites is Amoxicillin/clavulanic acid 875/125mg twice daily
• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable
• For severe and penetrating wounds, total treatment duration is usually 14 days (IV + oral). A longer duration of directed therapy is needed for injuries involving bones, joints and/or tendons
• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• In all cases, the patient's tetanus immunisation status must be ascertained and must be up to date and must be up to date
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites
• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on bites wounds and clenched fist injuries - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has a penicillin allergy use:

• A longer antibiotic course may be required according to clinical response
• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• For bites and clenched-fist injuries that are not infected, antibiotic therapy is usually not necessary for otherwise healthy individuals if the risk of wound infection is low (e.g. small wounds not involving deeper tissues that present within 8 hours and can be adequately debrided and irrigated). Give presumptive therapy if the risk of wound infection is high
• In all cases, the patient's tetanus immunisation status must be ascertained and must be up to date
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites
• For wounds on the hands, feet or face, or if infection progresses despite antibiotic therapy, consider surgical consultation. Surgical advice may also be sought on the appropriateness of primary versus delayed wound closure

References:

See section on bites wounds and clenched fist injuries - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has a penicillin allergy give:

OR if the patient is at an increased risk of MRSA infection, in place of the regimen above give:

Code for ciprofloxacin iv and clindamycin iv is: 3bit

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2bit

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable
• For severe and penetrating wounds, total treatment duration is usually 14 days (IV + oral). A longer duration of directed therapy is needed for injuries involving bones, joints and/or tendons
• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• In all cases, the patient's tetanus immunisation status must be ascertained and must be up to date
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on bites wounds and clenched fist injuries - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy use:

Code for Amoxicillin iv & Clavulanate is: 5bit

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2bit

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• A longer antibiotic course may be required according to clinical response
• Depending on microbiological findings from wound swab, the usual oral step down for animal or human bites is Amoxicillin/clavulanic acid 875/125mg twice daily
• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable
• For severe and penetrating wounds, total treatment duration is usually 14 days (IV + oral). A longer duration of directed therapy is needed for injuries involving bones, joints and/or tendons
• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• In all cases, the patient's tetanus immunisation status must be ascertained and must be up to date
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on bites wounds and clenched fist injuries - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Incision and drainage is the key therapeutic intervention for boils and carbuncles

Are antibiotics indicated (> 5 cm abscess or surrounding cellulitis)?

• Yes, antibiotics are indicated
• No, antibiotics not required

For treatment in a patient where antibiotics are not normally indicated (5 cm or less abscess or surrounding cellulitis):

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Would you class the cellulitis as mild/moderate or severe?

• Mild/Moderate
• Severe

• Choose severe if there are significant systemic features or no improvement in > 48hours

Would you class the cellulitis/abscess as mild/moderate or severe?

• Mild/Moderate
• Severe

• Choose severe if there are significant systemic features or no improvement in > 48hours

Is the patient an adult or a child?

• Adult
• Child (< 12 years)

Would you class the cellulitis/abscess as mild/moderate or severe?

• Mild/Moderate
• Severe

• Choose severe if there are significant systemic features or no improvement in > 48hours

Does the patient have a history of previous nmMRSA colonisation?

• Yes
• No

• Please check the patient's previous admission details. Areas with a high level of nmMRSA prevalence include detention centres, army barracks, remote communities and gaols
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is the patient an adult or a child?

• Adult
• Child (< 12 yrs)

Does the patient have a history of previous nmMRSA colonisation?

• Yes
• No

• Please check the patient's previous admission details. Areas with a high level of nmMRSA prevalence include detention centres, army barracks, remote communities and gaols
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Does the patient have a history of previous nmMRSA colonisation?

• Yes
• No

• Please check the patient's previous admission details. Areas with a high level of nmMRSA prevalence include detention centres, army barracks, remote communities and gaols
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Does the patient have a history of previous nmMRSA colonisation?

• Yes
• No

• Please check the patient's previous admission details. Areas with a high level of nmMRSA prevalence include detention centres, army barracks, remote communities and gaols
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Mild/moderate cellulitis from carbuncle with non-life threatening penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility use:

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Treatment for 5 days is generally sufficient, but a longer duration of therapy may be required for patients who are slow to respond or have a more severe infection
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

References:

See section on boils and carbuncles - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Mild/moderate cellulitis from carbuncle with life threatening penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

Code for clindamycin orally is: 5cac

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Treatment for 5 days is generally sufficient, but a longer duration of therapy may be required for patients who are slow to respond or have a more severe infection
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

References:

See section on boils and carbuncles - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Mild/moderate cellulitis from carbuncle with life threatening penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Treatment for 5 days is generally sufficient, but a longer duration of therapy may be required for patients who are slow to respond or have a more severe infection
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

References:

See the CHAMP guidelines on the intranet for further information on antibiotic treatment in a child

Mild/Moderate cellulitis from carbuncle with no penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained
• Treatment for 5 days is generally sufficient, but a longer duration of therapy may be required for patients who are slow to respond or have a more severe infection

References:

See section on boils and carbuncles - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For empirical therapy in a patient with mild penicillin allergy; while awaiting the results of cultures and susceptibility testing, use:

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see Therapeutic Guidelines for details)
• For oral regimens see the mild/moderate infection section
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

References:

See section on boils and carbuncles - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For empirical therapy in a patient with no penicillin allergy, while awaiting the results of cultures and susceptibility use:

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see Therapeutic Guidelines for details)
• For oral regimens see the mild/moderate infection section
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Mild cellulitis from a carbuncle in an adult at risk of nmMRSA or with non-life threatening penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

Code for clindamycin orally is: 5cac

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Treatment for 5 days is generally sufficient, but a longer duration of therapy may be required for patients who are slow to respond or have a more severe infection
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

References:

See section on carbuncles - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Mild/moderate cellulitis from a carbuncle in a child at risk of nmMRSA or with non-life threatening penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

References:

See section on carbuncles - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Severe cellulitis/abscess in a patient at risk of nmMRSA can be treated with vancomycin and Cefazolin:

Code for vancomycin is: 2cac

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see Therapeutic Guidelines for details)
• For oral regimens see the mild/moderate infection section
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained
• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Severe cellulitis/abscess in patients with severe penicillin hypersensitivity can be treated with vancomycin:

Code for vancomycin is: 2cac

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see Therapeutic Guidelines for details)
• For oral regimens see the mild/moderate infection section
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained
• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Severe cellulitis/abscess in adult patients at risk of nmMRSA should be treated with vancomycin and flucloxacillin:

Code for vancomycin is: 2cac

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see Therapeutic Guidelines for details)
• See the mild/moderate treatment section for nmMRSA for oral step down options
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained
• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Is there a purulent focus for infection such as an abscess or carbuncle or history of penentrating trauma?

• Yes
• No

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Would you class the cellulitis as mild/moderate or severe?

• Mild/Moderate
• Severe

• Choose severe if there are significant systemic features or no improvement in > 48hours

• Mild/Moderate
• Severe

Would you class the cellulitis/abscess as mild/moderate or severe?

• Mild/Moderate
• Severe

• Choose severe if there are significant systemic features or no improvement in > 48hours

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Are there suggestive signs of erysipelas or S.pyogenes? (eg nonpurulent, recurrent or spontaneous, rapid progression with no associated wound or ulcer)

• Yes
• No

• Erysipelas typically presents as a rapidly progressing erythematous skin lesion that has a sharply demarcated, raised edge
• Erysipelas is most common in infants, indigenous patients, young children and older adults
• Classically, erysipelas involves either facial skin in a butterfly pattern, or the lower legs
• Spontaneous rapid spreading cellulitis is most commonly due to S.pyogenes or another streptococci

Are there suggestive signs of erysipelas or S.pyogenes? (eg nonpurulent, recurrent or spontaneous, rapid progression with no associated wound or ulcer)

• Yes
• No

• Erysipelas typically presents as a rapidly progressing erythematous skin lesion that has a sharply demarcated, raised edge
• Erysipelas is most common in infants, indigenous patients, young children and older adults
• Classically, erysipelas involves either facial skin in a butterfly pattern, or the lower legs
• Spontaneous rapid spreading cellulitis is most commonly due to S.pyogenes or another streptococci

For mild/moderate cellulitis in a patient with penicillin hypersensitivity (non-life threatening) use as a single agent:

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For mild/moderate cellulitis in an adult with immediate (life threatening) penicillin hypersensitivity, or MRSA risk factors use as a single agent:

Code for clindamycin orally is: 5cel

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For mild/moderate cellulitis in a patient with signs of S.pyogenes use as a single agent:

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For mild/moderate cellulitis in a patient without signs of S.pyogenes or if S.aureus is suspected, use as a single agent:

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For empirical therapy of severe cellulitis in an adult with mild penicillin allergy; while awaiting the results of cultures and susceptibility testing, use:

• A total duration of therapy of 5 to 10 days (IV + PO) is recommended
• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary
• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• For patients with significant systemic symptoms, assess for necrotising fasciitis or underlying myonecrosis, see the Therapeutic Guidelines section on necrotising skin and soft tissue infections
• For patients with associated bacteraemia see the severe sepsis section or the severe sepsis: directed therapy section of the Therapeutic Guidelines
• Vancomycin may also be needed in patients with severe sepsis or septic shock. (see the severe cellulitis treatment in a patient with severe penicillin allergy for the dosing nomogram and approval code if needed)

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For empirical treatment of severe cellulitis in a patient with life threatening penicillin hypersensitivity use vancomycin:

Code for vancomycin is: 2cel

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• A total duration of therapy of 5 to 10 days (IV + PO) is recommended
• Consider an early switch to oral clindamycin (within 48 hours), clindamycin has excellent oral bioavailability (90% orally bioavailable)
• In addition to treating cellulitis, examine patient for tinea of the feet and treat if necessary
• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage
• For patients with significant systemic symptoms, assess for necrotising fasciitis or underlying myonecrosis, see the Therapeutic Guidelines section on necrotising skin and soft tissue infections
• For patients with associated bacteraemia see the severe sepsis section or the severe sepsis: directed therapy section of the Therapeutic Guidelines

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For empirical therapy in a patient with no penicillin allergy, with signs of erysipelas or Streptococcus pyogenes while awaiting the results of cultures and susceptibility use:

• A total duration of therapy of 5 to 10 days (IV + PO) is recommended
• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary
• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• For patients with significant systemic symptoms, assess for necrotising fasciitis or underlying myonecrosis, see the Therapeutic Guidelines section on necrotising skin and soft tissue infections
• For patients with associated bacteraemia see the severe sepsis section or the severe sepsis: directed therapy section of the Therapeutic Guidelines
• Vancomycin may also be needed in patients with severe sepsis or septic shock. (see the severe cellulitis treatment in a patient with severe penicillin allergy for the dosing nomogram and approval code if needed)

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For empirical therapy in a patient with no penicillin allergy, without signs of erysipelas, or Streptococcus pyogenes while awaiting the results of cultures and susceptibility use:

• A total duration of therapy of 5 to 10 days (IV + PO) is recommended
• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary
• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• For patients with significant systemic symptoms, assess for necrotising fasciitis or underlying myonecrosis, see the Therapeutic Guidelines section on necrotising skin and soft tissue infections
• For patients with associated bacteraemia see the severe sepsis section or the severe sepsis: directed therapy section of the Therapeutic Guidelines
• Vancomycin may also be needed in patients with severe sepsis or septic shock. (see the severe cellulitis treatment in a patient with severe penicillin allergy for the dosing nomogram and approval code if needed)

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

What type of cellulitis does the patient have? (see table below)

• Periorbital (preseptal)
• Orbital (postseptal)

Classification of eye cellulitis

• Periorbital (preseptal) cellulitis - is a soft tissue infection of the eyelids, originating anterior to the orbital septum (the anatomical barrier separating the eyelids from the orbit). It is usually caused by local introduction of organisms from trauma or infection of the surrounding skin
• Orbital (postseptal) cellulitis - usually arises from infection (especially untreated) of paranasal sinuses or orbital trauma. It is less common but much more serious than periorbital (preseptal) cellulitis. Clinical symptoms are more pronounced; patients are generally unwell and may have reduced vision, limited or painful extra-ocular movement, or proptosis

Is the patient severely ill? (i.e. periorbital cellulitis is the primary reason for hospitalisation)

• Yes
• No

• In severe cases of periorbital cellulitis a CT scan should be performed to exclude sinusitis associated infection and treatment should continue as per orbital cellulitis

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Does the patient have risk factors for Haemophilus influenzae or active sinusitis? (see below)

• Yes
• No

• Patients at risk for Haemophilus influenzae include children under 5 years of age who are not fully vaccinated, especially those attending a daycare

Does the patient have risk factors for Haemophilus influenzae or active sinusitis? (see below)

• Yes
• No

• Patients at risk for Haemophilus influenzae include children under 5 years of age who are not fully vaccinated, especially those attending a daycare

Does the patient have risk factors for Haemophilus influenzae or active sinusitis? (see below)

• Yes
• No

• Patients at risk for Haemophilus influenzae include children under 5 years of age who are not fully vaccinated, especially those attending a daycare

Does the patient have risk factors for Haemophilus influenzae or active sinusitis? (see below)

• Yes
• No

• Patients at risk for Haemophilus influenzae include children under 5 years of age who are not fully vaccinated, especially those attending a daycare

If patient has severe immediate or delayed penicillin hypersensitivity and risk factors for Haemophilus influenzae:

Please contact infectious diseases for advice

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy or other risk factors use:

• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to intravenous therapy
• If oral flucloxacillin is not tolerated then cefalexin can be used to replace oral flucloxacillin
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy but MRSA and Haemophilus influenzae risk factors use:

• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy or Haemophilus influenzae risk factors but is at risk of MRSA use:

• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy or MRSA risk factors, but is at risk of Haemophilus influenzae infection use:

• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has delayed penicillin hypersensitivity and MRSA and Haemophilus influenzae risk factors use:

• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has delayed penicillin hypersensitivity and MRSA risk factors but no Haemophilus influenzae risk factors use:

• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has delayed penicillin hypersensitivity with no MRSA risk factors but with Haemophilus influenzae risk factors use:

• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has delayed penicillin hypersensitivity with no MRSA or Haemophilus influenzae risk factors use:

• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has a severe penicillin allergy use:

• Patients at risk for Haemophilus influenzae include children under 5 years of age who are not fully vaccinated, especially those attending a daycare
• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has a severe penicillin allergy use:

Code for clindamycin orally is: 7per

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Patients at risk for Haemophilus influenzae include children under 5 years of age who are not fully vaccinated, especially those attending a daycare
• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Does the patient have risk factors for Haemophilus influenzae or active sinusitis? (see below)

• Yes
• No

• Patients at risk for Haemophilus influenzae include children under 5 years of age who are not fully vaccinated, especially those attending a daycare

Does the patient have risk factors for Haemophilus influenzae or active sinusitis? (see below)

• Yes
• No

• Patients at risk for Haemophilus influenzae include children under 5 years of age who are not fully vaccinated, especially those attending a daycare

Does the patient have risk factors for Haemophilus influenzae or active sinusitis? (see below)

• Yes
• No

• Patients at risk for Haemophilus influenzae include children under 5 years of age who are not fully vaccinated, especially those attending a daycare

Does the patient have risk factors for Haemophilus influenzae or active sinusitis? (see below)

• Yes
• No

• Patients at risk for Haemophilus influenzae include children under 5 years of age who are not fully vaccinated, especially those attending a daycare

If patient has no penicillin allergy and no other risk factors use:

• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to broad spectrum intravenous therapy
• If oral flucloxacillin is not tolerated then cefalexin can be used to replace oral flucloxacillin
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes
• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy, or non-severe penicillin hypersensitivity, with MRSA and Haemophilus influenzae risk factors use:

Code for vancomycin is: 2per

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for cefotaxime or ceftriaxone is: 3per

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing
• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to broad spectrum intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

Vancomycin Dosing in Paediatrics

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy, with no Haemophilus influenzae risk factors but is at risk of MRSA use:

Code for vancomycin is: 2per

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage
• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable
• If methicillin-resistant S. aureus (MRSA) is suspected (eg if patient from a jail, detention centre or community with high MRSA prevalence), seek expert advice
• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing

• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to broad spectrum intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicllin allergy or non-severe allergy with no MRSA risk factors, but is at risk of Haemophilus influenzae infection use:

Code for cefotaxime or ceftriaxone is: 3per

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing
• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to broad spectrum intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has non-severe immediate or delayed penicillin hypersensitivity and MRSA risk factors but no Haemophilus influenzae risk factors use:

Code for vancomycin is: 2per

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing
• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to broad spectrum intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has non-severe immediate or delayed penicillin hypersensitivity with no MRSA or Haemophilus influenzae risk factors use:

• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing
• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to broad spectrum intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has severe immediate or delayed penicillin hypersensitivity use:

Code for IV clindamycin is: 3per

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Clindamycin can provide MRSA coverage, though this may be variable. Modify treatment based on susceptibility results. Vancomycin may be required
• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing
• For periorbital cellulitis without systemic features, 7 days of antibiotic treatment is usually sufficient. Extend therapy if the infection has not resolved completely by the end of the treatment course
• Review within 48 hours is essential to ensure the patient’s condition is improving. If symptoms and signs have not improved after 48 hours, consider switching to broad spectrum intravenous therapy
• Common pathogens causing periorbital cellulitis are Staphylococcus aureus and Streptococcus species, or, in patients who are not fully vaccinated, Haemophilus influenzae type b (Hib). Staphylococcal infection is more likely in patients with a local lesion such as a hordeolum, dacryocystitis or a wound. Herpes simplex virus and herpes zoster virus are other causes

References:

See section on periorbital cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

If patient has no penicillin allergy use:

Code for ceftriaxone is: 3per

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• If there is concern about possible MRSA infection please replace flucloxacillin with vancomycin (see dosing nomograms and calculators for dosing)
  • Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
  • Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage
• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable
• In most cases oral step down therapy should be amoxicillin+clavulanic acid 875+125 mg 12-hourly, for a total of 10-14 days (IV + PO)
• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing
• If orbital cellulitis is suspected, collect blood samples for culture. A CT scan of the orbits and sinuses should be performed in all cases of suspected orbital cellulitis, because a delay in diagnosis can result in visual compromise or spread to the cranial fossa. If there is intracranial extension, consider brain abscess, which requires empirical antibiotic therapy with activity against anaerobes
• The total duration of therapy (intravenous + oral) is usually 10 to 14 days

References:

See section on cellulitis of the eye - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has non-severe immediate or delayed penicillin hypersensitivity use:

Code for ceftriaxone is: 3cli

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2cli

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable
• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing
• In most cases oral step down therapy should be cefalexin 500 mg 6-hourly, for a total of 10 to 14 days (IV + PO)
• If orbital cellulitis is suspected, collect blood samples for culture. A CT scan of the orbits and sinuses should be performed in all cases of suspected orbital cellulitis, because a delay in diagnosis can result in visual compromise or spread to the cranial fossa. If there is intracranial extension, consider brain abscess, which requires empirical antibiotic therapy with activity against anaerobes
• The total duration of therapy (intravenous + oral) is usually 10 to 14 days

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on cellulitis of the eye - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has a severe penicillin allergy:

Code for IV ciprofloxacin is: 3cli

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2cli

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Ciprofloxacin can be used in children when it is the drug of choice
• In most cases oral step down therapy should be clindamycin 450 mg 8-hourly PLUS ciprofloxacin 750 mg 12-hourly, for a total duration of 10 to 14 days (IV + PO). Alternatively, trimethoprim+sulfamethoxazole may be used as a single agent (See eTG for dose)
• If the patient has concurrent sinusitis or risk factors for H. influenzae type b infection (eg children younger than 5 years who are not fully vaccinated), then seek specialist advice
• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable
• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing
• If orbital cellulitis is suspected, collect blood samples for culture. A CT scan of the orbits and sinuses should be performed in all cases of suspected orbital cellulitis, because a delay in diagnosis can result in visual compromise or spread to the cranial fossa. If there is intracranial extension, consider brain abscess, which requires empirical antibiotic therapy with activity against anaerobes
• The total duration of therapy (intravenous + oral) is usually 10 to 14 days

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on cellulitis of the eye - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

How severe is the infection? (see table below)

• Mild
• Moderate
• Severe

Classification of diabetic foot infection

How severe is the infection? (see table below)

• Mild
• Moderate
• Severe

Classification of diabetic foot infection

How severe is the infection? (see table below)

• Mild
• Moderate
• Severe

Classification of diabetic foot infection

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Has the patient received antibiotic treatment recently? Or is this a chronic infection?

• Yes, recent antibiotics or chronic unresolved infection
• No, no antibiotics recently and acute infection

Has the patient received antibiotic treatment recently? Or is this a chronic infection?

• Yes, recent antibiotics or chronic unresolved infection
• No, no antibiotics recently and acute infection

Has the patient received antibiotic treatment recently? Or is this a chronic infection?

• Yes, recent antibiotics or chronic unresolved infection
• No, no antibiotics recently and acute infection

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Has the patient received antibiotic treatment recently? Or is this a chronic infection?

• Yes, recent antibiotics or chronic unresolved infection
• No, no antibiotics recently and acute infection

Has the patient received antibiotic treatment recently? Or is this a chronic infection?

• Yes, recent antibiotics or chronic unresolved infection
• No, no antibiotics recently and acute infection

For acute mild diabetic foot in a patient with MRSA risk factors and no recent antibiotics give:

Code for PO clindamycin is: 7dfi

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Treatment may extend up to 4 weeks if slow to resolve
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa ciprofloxacin or piperacillin with tazobactam may be required

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

For mild diabetic foot in a patient with no penicillin allergy, no MRSA risk factors, on recent antibiotics or with chronic infection:

• Treatment may extend up to 4 weeks if slow to resolve
• In patients with severe renal failure amoxicillin dose may need to be reduced
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa ciprofloxacin or piperacillin with tazobactam may be required

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

For acute mild diabetic foot in a patient with no penicillin allergy, no MRSA risk factors and no recent antibiotics:

• Treatment may extend up to 4 weeks if slow to resolve
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa ciprofloxacin or piperacillin with tazobactam may be required

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

For mild diabetic foot in a patient with non-severe penicillin allergy, no MRSA risk factors and with chronic infection / on recent antibiotics give:

• It is safe to use cefalexin in patients who had a delayed nonsevere reaction to a penicillin in the distant past. It is also safe to use cefalexin in patients who have had a delayed nonsevere reaction recently, unless the reaction involved amoxicillin or ampicillin, because cross-reactivity between these drugs is possible
• Treatment may extend up to 4 weeks if slow to resolve
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa the empirical dosage of ciprofloxacin may need to be modified

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

For acute mild diabetic foot in a patient with non-severe penicillin allergy, no MRSA risk factors and not on recent antibiotics give:

• It is safe to use cefalexin in patients who had a delayed nonsevere reaction to a penicillin in the distant past. It is also safe to use cefalexin in patients who have had a delayed nonsevere reaction recently, unless the reaction involved amoxicillin or ampicillin, because cross-reactivity between these drugs is possible
• Treatment may extend up to 4 weeks if slow to resolve
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa the empirical dosage of ciprofloxacin may need to be modified

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

For mild diabetic foot in a patient with either life-threatening penicillin allergy, or with high MRSA risk, coupled with chronic infection or recent antibiotics give:

• Treatment may extend up to 4 weeks if slow to resolve
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa the empirical dosage of ciprofloxacin may need to be modified

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

For mild diabetic foot in a patient with non-life-threatening penicillin allergy:

• Treatment may extend up to 4 weeks if slow to resolve
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa ciprofloxacin or piperacillin with tazobactam may be required

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

Is MRSA infection suspected?

• Yes
• No

• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage

For moderate diabetic foot in patient with MRSA risk factors treatment will depend on whether patient can tolerate oral therapy:

If patient tolerates oral therapy give:

If patient cannot tolerate oral therapy give:

Code for IV ciprofloxacin and IV clindamycin is: 2dfi

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Continue antibiotics until infection has resolved but not necessarily until wound has healed. Usual duration is 1-2 weeks (IV + PO), however a longer duration is needed if deeper tissues are involved
• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• Please note trimethoprim and metronidazole both have excellent oral bioavailability (98% and 99% orally bioavailable), consider an early switch to oral therapy if is to be used
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa contact infectious diseases for advice

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

For moderate diabetic foot in patient with immediate severe penicillin hypersensitivity with MRSA risk factors treatment will depend on whether patient can tolerate oral therapy. Give either:

If patient cannot tolerate oral therapy give:

If patient tolerates oral therapy give:

Code for IV ciprofloxacin and IV clindamycin is: 2dfi

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Treatment may extend up to 4 weeks if slow to resolve, and even longer if deeper tissues are involved (e.g. osteomyelitis)
• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• Please note trimethoprim and metronidazole both have excellent oral bioavailability (98% and 99% orally bioavailable), consider an early switch to oral therapy if is to be used
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa contact infectious diseases for advice

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

For severe diabetic foot or moderate diabetic foot with sepsis in any patient intolerant of penicillin use:

Code for IV ciprofloxacin, IV clindamycin and vancomycin is: 2dfi

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for oral ciprofloxacin and oral clindamycin is: 7dfi

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• Modify therapy based on the results of culture and susceptibility testing. If results are not available by 72 hours and intravenous therapy is still required, consider monotherapy with amoxicillin+clavulanate if the patient is clinically improving. It is not necessary to continue treatment with activity against Pseudomonas aeruginosa and MRSA
• Continue antibiotics until infection has resolved but not necessarily until wound has healed. Usual duration is 3 weeks (IV + PO), however a longer duration is needed if deeper tissues are involved
• Please note clindamycin has excellent oral bioavailability (90% orally bioavailable), consider an early switch to oral if clindamycin is to be used
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa the empirical dosage of ciprofloxacin may need to be modified
• Wherever possible ensure that 2 x blood cultures are taken prior to administration of antibiotics to allow directed therapy
• If septic, door to needle time must be within ONE HOUR of recognition of septic shock
• If septic, repeat fluid bolus every 15 minutes until patient is normotensive.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment . Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return
• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state
• If cultures return sensitive to clindamycin this is often a good alternative to vancomycin with excellent tissue penetration
• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• Check the Therapeutic Guidelines for details on when to make the switch to oral antibiotics

---

Vancomycin Dosing in Adults

Actual body weight (kg)	CrClr < 20 mL/min	CrClr 20-40 mL/min	CrClr 40-60 mL/min	CrClr > 60 mL/min	Administer over(1)
< 40	15 to 20 mg/kg 48 to 72 hly	15 to 20 mg/kg 24-hly	15 to 20 mg/kg daily, in 1 or 2 divided doses	15 to 20 mg/kg 12-hly	---
40-49	750 mg 48 to 72 hly	750 mg 24 hly	750 mg daily, in 1 or 2 divided doses	750 mg 12 hly	1 hr 15 min
50-64	1000 mg 48 hly	1000 mg 24 hly	1000 mg daily, in 1 or 2 divided doses	1000 mg 12 hly	1 hr 40 min
65-78	1250 mg 48 hly	1250 mg 24 hly	1250 mg daily, in 1 or 2 divided doses	1250 mg 12 hly	2 hrs 5 min
79-92	1500 mg 48 hly	1500 mg 24 hly	1500 mg daily, in 1 or 2 divided doses	1500 mg 12 hly	2 hrs 30 min
93-107	1750 mg 48 hly	1750 mg 24 hly	1750 mg daily, in 1 or 2 divided doses	1750 mg 12 hly	3 hrs
> 108	2000 mg 48 hly	2000 mg 24 hly	2000 mg daily, in 1 or 2 divided doses	2000 mg 12 hly	3 hrs 30 min
Timing of 1st trough level(2)	48 hrs after the 1st dose(3)	Before the 3rd dose	48 hrs after the 1st dose(3)	Before the 4th dose	---

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

For moderate diabetic foot in patient intolerant of penicillin with no MRSA risk factors use:

• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• Please note metronidazole has excellent oral bioavailability (98% orally bioavailable), consider an early switch to oral if tolerated
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa the regimen may need to be modified

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

For moderate diabetic foot in a patient with no penicillin allergy and no signs of MRSA or sepsis use:

Code for IV Amoxicillin+Clavulanate is: 7dfi

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 1 week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Treatment may extend up to 4 weeks if slow to resolve
• If Pseudomonas aeruginosa is isolated from cultures of deep tissue specimens then the regimen may need to be changed to piperacillin and tazobactam with 6-hourly dosing
• Check the Therapeutic Guidelines for details on when to make the switch to oral antibiotics

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

For severe diabetic foot or moderate diabetic foot in a patient with sepsis use:

Code for piperacillin+tazobactam is: 7dfi

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 2 weeks. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2dfi

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Continue antibiotics until infection has resolved but not necessarily until wound has healed. Usual duration is 3 weeks (IV + PO), however a longer duration is needed if deeper tissues are involved
• Risk factors for MRSA infection include: residence in a jail or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Patients from the Kimberley, Pilbara, Mid West, Gascoyne and Goldfields-Esperance health regions potentially have higher rates of MRSA carriage
• Wherever possible ensure that 2 x blood cultures are taken prior to administration of antibiotics to allow directed therapy
• If septic, door to needle time must be within ONE HOUR of recognition of septic shock
• If septic, repeat fluid bolus every 15 minutes until patient is normotensive.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment . Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return
• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state
• If cultures return sensitive to clindamycin this is often a good alternative to vancomycin with excellent tissue penetration
• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• If Pseudomonas aeruginosa is isolated from cultures of deep tissue specimens then the empirical dose of piperacillin and tazobactam may need to be maintained at 6-hourly dosing for longer
• Check the Therapeutic Guidelines for details on when to make the switch to oral antibiotics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

For mild to moderate diabetic foot in a patient with non-life-threatening penicillin allergy:

Code for piperacillin+tazobactam is: 7dfi

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 1 week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Treatment may extend up to 4 weeks if slow to resolve
• If Pseudomonas aeruginosa is isolated from cultures of deep tissue specimens then the empirical dose of piperacillin and tazobactam may need to be increased to 6-hourly dosing
• Check the Therapeutic Guidelines for details on when to make the switch to oral antibiotics

References:

See section on diabetic foot infection management - Therapeutic Guidelines Group Melbourne

In patients without systemic symptoms, increased breastfeeding and gently expressing milk from the affected breast may prevent progression and resolve infection without antibiotics. In patients with systemic symptoms, or symptoms or signs that have not resolved after 24 to 48 hours of increased breastfeeding and expressing of milk, early antibiotic therapy is important to prevent abscess formation. Combine antibiotic therapy with increased breastfeeding and expressing of milk.

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

If the patient has no penicillin allergy treat with:

• If mastitis is not associated with breastfeeding, seek expert advice for management
• If infection does not resolve with antibiotic therapy, evaluate the patient for an abscess and consider whether infection is caused by another pathogen
• If the patient has severe cellulitis, treat as Cellulitis associated with systemic features for initial treatment. Switch to oral therapy (as above) when symptoms are resolving
• Acute mastitis is usually associated with breastfeeding and is often caused by Staphylococcus aureus. Poor infant positioning, milk stasis and nipple damage are contributing factors. Breastfeeding or expressing milk (manually or via a pump) from the infected breast is safe and should be continued
• In patients without systemic symptoms, increased breastfeeding and gently expressing milk from the affected breast may prevent progression and resolve infection without antibiotics
• In patients with systemic symptoms, or symptoms or signs that have not resolved after 24 to 48 hours of increased breastfeeding and expressing of milk, early antibiotic therapy is important to prevent abscess formation. Combine antibiotic therapy with increased breastfeeding and expressing of milk

References:

See section on lactational mastitis - Therapeutic Guidelines Group Melbourne

If the patient has non-severe penicillin allergy treat with:

• It is safe to use cefalexin in patients who had a delayed nonsevere reaction to a penicillin in the distant past. It is also safe to use cefalexin in patients who have had a delayed nonsevere reaction recently, unless the reaction involved amoxicillin or ampicillin, because cross-reactivity between these drugs is possible. For patients who have had a recent delayed nonsevere reaction to amoxicillin or ampicillin, use the drug recommended for patients with immediate (nonsevere or severe) or delayed severe hypersensitivity
• If mastitis is not associated with breastfeeding, seek expert advice for management
• If infection does not resolve with antibiotic therapy, evaluate the patient for an abscess and consider whether infection is caused by another pathogen
• If the patient has severe cellulitis, treat as Cellulitis associated with systemic features for initial treatment. Switch to oral therapy (as above) when symptoms are resolving
• Acute mastitis is usually associated with breastfeeding and is often caused by Staphylococcus aureus. Poor infant positioning, milk stasis and nipple damage are contributing factors. Breastfeeding or expressing milk (manually or via a pump) from the infected breast is safe and should be continued
• In patients without systemic symptoms, increased breastfeeding and gently expressing milk from the affected breast may prevent progression and resolve infection without antibiotics
• In patients with systemic symptoms, or symptoms or signs that have not resolved after 24 to 48 hours of increased breastfeeding and expressing of milk, early antibiotic therapy is important to prevent abscess formation. Combine antibiotic therapy with increased breastfeeding and expressing of milk

References:

See section on lactational mastitis - Therapeutic Guidelines Group Melbourne

If the patient has severe penicillin allergy treat with:

Code for PO clindamycin is: 10lac

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 10 days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• If mastitis is not associated with breastfeeding, seek expert advice for management
• If infection does not resolve with antibiotic therapy, evaluate the patient for an abscess and consider whether infection is caused by another pathogen
• If the patient has severe cellulitis, treat as Cellulitis associated with systemic features for initial treatment. Switch to oral therapy (as above) when symptoms are resolving
• Acute mastitis is usually associated with breastfeeding and is often caused by Staphylococcus aureus. Poor infant positioning, milk stasis and nipple damage are contributing factors. Breastfeeding or expressing milk (manually or via a pump) from the infected breast is safe and should be continued
• In patients without systemic symptoms, increased breastfeeding and gently expressing milk from the affected breast may prevent progression and resolve infection without antibiotics
• In patients with systemic symptoms, or symptoms or signs that have not resolved after 24 to 48 hours of increased breastfeeding and expressing of milk, early antibiotic therapy is important to prevent abscess formation. Combine antibiotic therapy with increased breastfeeding and expressing of milk

References:

See section on lactational mastitis - Therapeutic Guidelines Group Melbourne

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

For necrotising fasciitis or cellulitis sourced sepsis, treat with:

Code for piperacillin+tazobactam, meropenem, ciprofloxacin iv, vancomycin and clindamycin iv is: 2nec

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• If the patient only has a single IV line it is important to give the other antibiotics before vancomycin as it has the longest infusion time
• Infectious diseases should be involved as soon as possible with all hospital acquired sepsis or necrotising fasciitis, cases as a wide range of organisms could be causing the infection which may not be covered by the above regimen
• Wherever possible ensure that 2 x blood cultures are taken prior to administration of antibiotics to allow directed therapy
• If septic, door to needle time must be within ONE HOUR of recognition of septic shock
• If septic, repeat fluid bolus every 15 minutes until patient is normotensive.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment . Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on necrotising fasciitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For necrotising fasciitis or cellulitis sourced sepsis, treat with:

Code for meropenem, ciprofloxacin iv, vancomycin and clindamycin iv is: 2nec

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• In patients with penicillin hypersensitivity, the rate of immune-mediated cross-reactivity with carbapenems is approximately 1%; therefore, meropenem can be considered in supervised settings. However, in patients with a history of a severe cutaneous adverse reaction (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome / toxic epidermal necrolysis [SJS/TEN], acute generalised exanthematous pustulosis [AGEP]), consider meropenem only in a critical situation when there are limited treatment options
• If the patient only has a single IV line it is important to give the other antibiotics before vancomycin as it has the longest infusion time
• Infectious diseases should be involved as soon as possible with all hospital acquired sepsis or necrotising fasciitis, cases as a wide range of organisms could be causing the infection which may not be covered by the above regimen
• Wherever possible ensure that 2 x blood cultures are taken prior to administration of antibiotics to allow directed therapy
• If septic, door to needle time must be within ONE HOUR of recognition of septic shock
• If septic, repeat fluid bolus every 15 minutes until patient is normotensive.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment . Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on necrotising fasciitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

In a patient with immediate penicillin hypersensitivity consider treatment with:

Code for meropenem, vancomycin, ciprofloxacin iv and clindamycin iv is: 2nec

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• In patients with penicillin hypersensitivity, the rate of immune-mediated cross-reactivity with carbapenems is approximately 1%; therefore, meropenem can be considered in supervised settings. However, in patients with a history of a severe cutaneous adverse reaction (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome / toxic epidermal necrolysis [SJS/TEN], acute generalised exanthematous pustulosis [AGEP]), consider meropenem only in a critical situation when there are limited treatment options
• If the patient only has a single IV line it is important to give the other antibiotics before vancomycin as it has the longest infusion time
• Infectious diseases should be involved as soon as possible with all hospital acquired sepsis or necrotising fasciitis, cases as a wide range of organisms could be causing the infection which may not be covered by the above regimen
• Wherever possible ensure that 2 x blood cultures are taken prior to administration of antibiotics to allow directed therapy
• If septic, door to needle time must be within ONE HOUR of recognition of septic shock
• If septic, repeat fluid bolus every 15 minutes until patient is normotensive.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment . Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on necrotising fasciitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is the infection a superficial site infection or deep incisional site infection? (see below)

• Deep incisional surgical site infections are any surgical sites involving the fascia or muscle
• If the patient is displaying any systemic features treat as if a deep incisional infection regardless of the surgery type

• Wound infection is from a superficial surgical site
• Wound infection is a deep incisional surgical site or patient has systemic features

Is the infection a superficial site infection or deep incisional site infection? (see below)

• Deep incisional surgical site infections are any surgical sites involving the fascia or muscle
• If the patient is displaying any systemic features treat as if a deep incisional infection regardless of the surgery type

• Wound infection is from a superficial surgical site
• Wound infection is a deep incisional surgical site or patient has systemic features

Is the infection a superficial site infection or deep incisional site infection? (see below)

• Deep incisional surgical site infections are any surgical sites involving the fascia or muscle
• If the patient is displaying any systemic features treat as if a deep incisional infection regardless of the surgery type

• Wound infection is from a superficial surgical site
• Wound infection is a deep incisional surgical site or patient has systemic features